Disclosure of Relevant Financial Relationships
Annual Disclosure for Executive Council Members & Committee Chairs Only
Name
*
First Name
Last Name
Email
*
example@example.com
What is your appointed position?
Officer
Committee Chair
Committee Vice Chair
What Officer Position do you hold?
President
President Elect
Secretary
Treasurer
Councilor
Which Committee?
Education & Research
Ethics
Information & Technology
Membership
Program
Year of appointment
Please Select
2022-2023
2023-2024
Disclosure of Relevant Financial Relationships
Please list the names of proprietary entities producing healthcare services and/or goods with which you/your spouse/partner have or have had a relevant financial relationship in the past 12 months (non-profit or government organizations and non-health care related companies are exempt).
WITH RESPECT TO THIS SPECIFIC CME ACTIVITY (please check one):
*
No, I do not have a relevant financial relationship.
Yes, I do have a relevant financial relationship.
Provide pertinent information below:
Rows
Company
Grant/Research Support
Consultant
Stock Shareholder
Speaker's Bureau
Honoraria
Employee
Other (please explain)
Attestion
I attest that the above information is true.
Signature
*
Submit
Should be Empty: